Provider Demographics
NPI:1568450757
Name:DAVIS, GLENN R (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:R
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:417 N UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-3108
Mailing Address - Country:US
Mailing Address - Phone:501-666-0249
Mailing Address - Fax:501-666-4340
Practice Address - Street 1:417 N UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-3108
Practice Address - Country:US
Practice Address - Phone:501-666-0249
Practice Address - Fax:501-666-4340
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARC4810207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR51306Medicare ID - Type Unspecified
D84182Medicare UPIN
AR57592Medicare ID - Type UnspecifiedGRP